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FOR OFFICE USE: FOR OFFICE USE- /0 -0 _ ,v APPLICATION FOR SANITATION PERMIT ------- --- j-- o G--- - -` -------------- No. 77 .33 (Complete in Triplicate) Permit Date Issued___ _______________________________________________.___- This Permit Expires 1 Year From Date Issued t Application is hereby made to the San Joaquin Local.Health District for a permit to construct and.install the work herein described, � This application is made in compliance with County Ordinance No. 549 and existing Rules and Regulations: COCAION � --------------------------- --JOB ADDRESS/ CENSUS TRACT--------------------- ---------- Owners Name7 AddressG -}� ` r ,---------------------------------------------City --------------- ------ --------Zip-- -- --- -- -- - -------- Contractor's Name-- t�C ---------- ----- ----------- - _ -- - 1---1---= License # ,l_..-� Installation will serve: �� Residence ❑otelAp❑art Other- ------ Number mere Trailer Court ❑ � � � ' 1 ' } Number of living units:------__-Number of.bedrooms _ ____Garbage Grinder_.._..:,__ .Lot Size.__ J �-______ __________________________T__. Water Supply: Public System andFname---------------------------- -- .•----------_.::__-- -__ ---.---.-_ ----------------------------------Private Character of soil to a depth of 3 feet: Sand ❑ Silt ❑ Clay ❑ : Peat ❑ Sandy Loam ❑ 'Clay Loam ❑ Hardpan ❑ . Adobe Fill Material_..._,------If yes, type-------------------------------- f {Plot plan, showing size of lot, location of system in relation to wells, buildings, etc, must be placed on reverse side.) NEW INSTALLATION: (No septic tank ,or -seepage pit permitted if public sewer is available within 200 feet,) . PACKAGE TREATMENT [ ] SEPTIC TANK [, Size_'T.eX r___r—/P-------------------- Liquid Depth.__ _� __----- I . - Capacity---/L c),.C.,__Type-�/ - -:Material__..-----No. Compartments-----�----- p i T, ------ --� Distance to nearest: Well--------J -------- ------- --------------- Foundation__/Q___-__________--.Prop. Line- -----:-------- _}__-� r --------- Total Len th .' . --------------------------- LEACHING LINE . No, of Line/s_.___.:.___------ -3 Length of each line._.��_�--__., �� ✓, f 1 7 i D' Box_._ [/--:--Type Filter Material cf Depth Filter Material_.__�( ------------ ---------- .. , . , . �. / E i s Distance,to nearest: Well____ ....___________Foundation _!_ ___-_______ __Property _____.._____._____ __ SEEPAGE PIT Depth__e��f___Diameter.:: Yf __._Number__- ___o __.___ ___.___ Rock Filled Yes)0- No ❑ 7 q �; Water Table Depth.__�__ _ _ i____ _________________________Rock Size__ ,_ - a 1 bistance`to nearest: Well.' _f___________ _____ _______Foun'dation__ :_ ._'.___._ _Prop. Line__{ --`-'.__.__. ;€ f REPAIR/ADDITION (Prev. Sanitation Permit#___ ------------------------- -------Dote:--------=------------------------- ----------- Septic Tank (Specify Requirements)- = = 3 E ---- ---------- Disposal Field (Specify Requirements)--------------------- -------- --------------------------- - a - --------------------------=----------- ------ ------ =-------------- ------------------- --------------- ------ ----------------------------------------- (Draw existing and required addition on reverse side) I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin County Ordinances, State Laws, and Rules and Regulations of'the San Joaquin Local Health District, Home owner or licensed agents signature certifies the following: "I certify that in the performance of the work for which this permit is issued, I shall not employ any person in such manner as to become b' ct to orkm n's Compensation laws of—California-11 Sion ----- ------ ----------- - --------------- _ =------ _`Owner ;. = �' Title................ -- t 3' (If other an owner) �- _ �` �-~ � � FOR-DEPARTMENT'USE ONLY, " I APPLICATION ACCEPTED BY - =----------------------------------------------------------DATE.- - DIVISION OF LAND NUMBER --------------------------'�----------------------------------------------------- -- -DATE.------------------ --------------------- ENTSa ---- -- - = -------- -------- ....................................... -c :------------------------------------i .� ---------'"- ------------------------------------------------------- ADDITIONAL COMM -- - -- ----;----------- -- ----------------------------- ----------------------------------- -------------- -------------- -------- - -------------------------- ----------- = ------------------------------------------------------- Final.lns-inspection b :Date = p ---------------------;-------- EH 13 24 SAN JOAQUIN LOCAL HEALTH DISTRICT F&S 21677 R€V, 7/76 3M